The Safety of Chiropractic Care – by Dr. Alex Jimenez

“Doctor, are chiropractic adjustments safe?”

This is one of the most common questions asked by people seeking or considering chiropractic care along with

“What are the risks?”
“Can I receive spinal adjustments without the chiropractor adjusting my neck?”
“Do chiropractic adjustments cause arthritis or even strokes?”
With media scrutiny over natural health procedures, specifically chiropractic and cervical adjustments, these are very important and serious questions, especially when one’s health is a priority. As a practicing chiropractor, I welcome the opportunity to address these questions. Chiropractic care is profoundly safe, and this article summarizes the current research, providing answers to these common questions and misconceptions.

Myths vs. Facts
In 1990, when I started working in the chiropractic profession, a common concern that patients had about chiropractic care was that “too many adjustments would cause arthritis.”  Years later, science has affirmed what chiropractors have always seen and known to be true in clinical practice – that in fact chiropractic care is not only one of the most popular forms of care for people with arthritic conditions but one of the most effective.1,2

Unfortunately, for hundreds of years, health care practices have been permeated by folklore, sometimes known as “old wives tales.”  The trend continues today.  A 2010 study of over 1,000 board-certified American pediatricians found that over 75% of the doctors subscribe to at least one known health care myths.3 These include the myths that eating chocolate causes acne, listening to Mozart will make a baby smarter, and swimming within 30 minutes of eating is not safe.  Many doctors in this study were also found guilty of not knowing the expected protocols for treating burns, healing wounds, administering Aspirin to children, and safely dealing with seizures.

A review of the current literature indicates that frequent or extreme complications of chiropractic care should also be included in the list of the most common medical myths prevalent even in our medical offices.

Spinal Care vs. Chiropractic Care

The spinal column’s role in overall health cannot be undermined as it houses the brainstem, spinal cord, and central nerve system.  Thus, for optimal health the spinal column must be examined and cared for by a skilled doctor.

Specifically, the foundation of chiropractic care teaches that damage to the spine, and misalignments of the vertebrae (subluxations) create interference in the nerve system, which are therefore reduced and corrected through specific chiropractic adjustments.4,5

On that basis, chiropractic adjustment techniques have historically been rooted in precision and accuracy.  Although there are now many unique chiropractic techniques taught in professional schools and in continuing education, these techniques commonly focus on the evaluation and measurement of subluxation patterns in the spine and the specific protocols used to reduce the areas of misalignment.  In contrast, most other health care practices addressing the spine, never mind non-medical procedures attempted at home, are for the most part, generalized treatments of pain, global mobilizations of joints, and overall tractions of entire regions of the spinal column.

Receiving a specific chiropractic adjustment to reduce a subluxation is immensely different from receiving any form of “treatment” on the spine.  Admittedly, I did not understand this practice in my first 20 years of receiving chiropractic adjustments.  Until I attended chiropractic school and learned the techniques and analyses used in chiropractic science, I thought that chiropractic adjustments were all one-of-the-same.  I can understand how the general public might also construe this misconception – I did and I grew up in a chiropractic family.  Subluxations and adjustments are specific; the more extensive the analysis used by the chiropractor, the more precise the adjustment, and thus the better improvement in the patient’s health.

In my experience, the majority of the “chiropractic horror stories” shared in folklore, and even many of the cases cited by medical research, fall into one of two categories:

(a)    The case of a the patient receiving care without extensive and correct analysis

(b)   A person receiving spinal care incorrectly identified as “chiropractic care” administered by someone other than a licensed Doctor of Chiropractic

In fact, a 1995 report in the Journal of Manipulative and Physiological Therapeutics revealed that many “manipulations,” incorrectly attributed to chiropractors, had been rendered by non-chiropractic professionals including GPs, osteopaths, and physiotherapists, and even laypeople including a wife, a Kung-Fu practitioner, a blind masseur, and an Indian barber.6,7 Therefore before someone suggests they were hurt or injured by a “chiropractor,” it is imperative to learn more about their experience.  In all likelihood some level of scrutiny was overlooked – or they weren’t seeing a licensed chiropractor at all.

Modern chiropractors use advanced technological analyses such as X-ray, surface electromyography (sEMG), thermography, and digital postural analysis, along with traditional chiropractic methods of motion and static palpation, leg length analysis, and visual postural inspection to make a diagnosis and determine the appropriate adjustment.  Naturally, to use layman’s terminology, if a patient presented to the chiropractor with a low left hip, and the chiropractor adjusted the left hip “even lower,” the patient would get worse.  For this reason, your Doctor of Chiropractic is not only highly trained but expected under every state and provincial law to thoroughly assess your spine and condition prior to making recommendations or giving adjustments.

What about stroke?

Since the 1990s, the most extreme fallacy about chiropractic care is that “adjustments of the cervical spine cause strokes.”  As a practitioner, I am pleased to observe greater inter-professional cooperation between physicians and chiropractors, but I am disappointed by the increasing number of patients who have consulted me following a discussion with their medical doctor and told to “not get their necks adjusted.”

A basic understanding of the origins of chiropractic care, and the critical function, anatomy, and physiology of the central nerve system demonstrates why the suggestion that patients should “not get their necks adjusted” is absurd.  While chiropractors are concerned with the reduction of nerve system stress caused by spinal subluxations throughout the entire spine, one must understand that all spinal nerves first pass through the upper cervical spine.  Therefore, interference to the nerves passing from the brain through the spinal cord to any area of the body could occur either at the associated spinal segment where the peripheral nerve exits the spinal column, or at any place higher, including the upper cervical spine.  Historically, Dr. B.J. Palmer, who developed the modern chiropractic profession, focused the majority of his research and efforts into the reduction of upper cervical spine subluxations, expressing that upper cervical subluxations were the foremost cause of disease and dysfunction compared to other subluxations in the spine.8 Years later, science continues to affirm the importance of upper cervical alignment.  It has been demonstrated that abnormal cervical alignment is a leading cause and an almost universal finding related to not only cervicogenic pain and headaches, but also the development of scoliosis9,10 and even sudden infant death syndrome (SIDS).11.12,13 This awareness of the basic physiology of the nerve system is enough to understand the utmost importance of reducing subluxations in the cervical spine, above all other areas of the nerve system.

The “stroke hypothesis” stems from the theory that the irritation of the vertebral arteries, which pass through the cervical vertebrae, could lead to an ischemic stroke by causing accumulated plaque in the arteries to be dislodged.  As strokes may cause serious, permanent impairments in a person’s health, there has naturally been much interest and research in this topic.

Consider how plaque develops in the arterial system of the body.  Exposure to the known risks of poor diet, alcohol consumption, and smoking over a period of many years may cause molecular plaquing in the arteries, and it is true that when those molecules become dislodged, they can affect the brain, which is known as a stroke.  Unfortunately, your family doctor or your chiropractor can’t prevent this from happening – you would need immediate emergency medical attention in hospital to prevent this from occurring.

Warning signs that a stroke may be about to occur include upper back pain, neck pain, and headaches.  Naturally, people dealing with these symptoms may consult their chiropractor, hoping for a resolution of pain.  Many may also consult their MDs and/or other trusted health care providers.  Unfortunately, such pre-stroke symptoms as back pain, neck pain, and headaches may not explicitly appear to be the early stages of a vascular incident without the “red-flag” accompanying symptoms of blurred vision, dizziness, slurred speech, facial drooping, and lack of coordination.  Therefore, as it is not standard practice for chiropractors or medical physicians to refer every case of back pain or headaches to the emergency room, patients may receive chiropractic or medical intervention without knowing that a stroke is ensuing.

When is a chiropractor or medical doctor negligent?  If a patient visits the doctor’s office with neck pain and headaches while showing the classic signs of stroke (slurred speech, dizziness, poor coordination, etc.), the doctor is obligated to identify this and ensure that a stroke is not about to happen.  If, after examination, a doctor identifies that a stroke may be forthcoming, the doctor must see that the patient receives the necessary immediate medical attention.  Doctors who do not rule out the possibility of an imminent stroke or do not ensure necessary medical attention if a stroke is indeed forthcoming, would indeed be negligent – but this is very far from “causing” the person’s stroke, whether or not any treatment was rendered.

In fact, although a chiropractic adjustment would not slow down the incidence of the stroke, 2008 research shows that it would no more accelerate it than a visit to the medical doctor.  In an article published in SPINE, a multi-disciplinary team of researchers found that while strokes are very rare events in the general public, there was only an increased correlation between chiropractic visits and the occurrence of stroke, due to patients with headaches and neck pain seeking care before their stroke.14 Notably, the correlation of medical visits and strokes matched that of chiropractic visits and strokes; neither form of care was shown to increase the risk of stroke.  In either case, the unfortunate patient was headed for a vascular incident.  The occurrence of a stroke after a visit to the chiropractor (or the medical doctor) provides no association of cause, only correlation.15

Is your chiropractor required to warn you about the possibility of a stroke with a chiropractic adjustment?  Interestingly, Dr. Christopher Kent, who is an attorney, independent researcher, and president of the Foundation for Vertebral Subluxation, has expressed that “such informed consent must be based on appropriate information and since there is no scientific evidence that chiropractic adjustments or neck manipulations actually cause strokes, it is inappropriate to require a doctor to suggest that such a risk exists.”16 Nevertheless, most state and provincial laws require Doctors of Chiropractic to disclose a remote risk of stroke to their patients, for this is common practice for “material risks” even when the likelihood of occurrence is very small.17

Long-term Benefits of Chiropractic Care

Rather than study isolated reports of adverse incidences which may (or may not) occur within one visit to the chiropractor, it is more revealing to measure the long-term benefits of chiropractic care.  Ultimately, studies consistently demonstrate that a healthier spine relates to a healthier person.

Beyond symptomatic relief, a growing number of chiropractors place emphasis on corrective care and spinal hygiene, to maintain and promote the health of the spinal column and nerve system.

Without maintenance of spinal health, we now know through numerous studies that posture misalignment not only affects neurology but also the vascular system.  A 2004 study revealed that older men and women with hyperkyphotic postures have increased rates of death, specifically associated with increased atherosclerosis.18 With atherosclerosis increasing the incidence of an ischemic stroke, it is only logical for health-conscious individuals trying to prevent strokes to maintain healthy posture through chiropractic care.

Further, whereas a 2005 study showed that the reversal of the normal cervical curvature results in vascular changes in the spinal cord,19 the maintenance of this proper alignment should be of highest importance to those interested in the prevention of vascular incidents.

Statistically, the incidence rates favour those individuals receiving chiropractic care.  In 1995, the Journal of Manual and Physiological Therapeutics published the risk of fatal stroke associated with chiropractic cervical adjustments.  Although no cause was shown in the article, the correlation is estimated to be 1 in 400,000 or 0.00025%.20 Newer studies suggest the risk may be as low as 1 in 6 million, 0.00002%.21 Notably, the National Center for Health Statistics indicates the mortality rate from stroke in the general population is more than twice the rate of the most conservative estimates correlating chiropractic.  The risk in the general population is 1 in 175,000 or 0.00057%.22

Not only is the risk of death from stroke after a cervical adjustment substantially less than the risk of fatal stroke in the general population, other long-term studies of chiropractic patients have shown:

Improved lung capacity, athletic ability, and vision23
Better functional capacity, and reduced relapse of prior disability24
Better overall health and greater activity levels25
Enhanced DNA repair and enzyme activity; reduced impact of oxidative stress26
Fewer hospital visits, reduced pharmaceutical costs, and medical expenditures27
Improvement in health, wellness, and quality of life28,29
The Final Verdict: Malpractice Claims

Lastly, as it is always possible that research could be slanted based on who was conducting it, perhaps the best measures of safety are the malpractice insurance costs for chiropractors and the actual frequency and success of claims filed against them.  No one pays closer attention to injury statistics than Malpractice Insurance carriers.

According to the Canadian Medical Protective Association, annual malpractice rates for Ontario medical doctors range from $1,572 for the family physician and $7,332 for the neurologist, to $44,520 for the Obstetrician.30 By comparison, the Canadian Chiropractic Protective Association’s standard rate for chiropractic malpractice insurance is less than $1,300 per year.  Notably, the first-year doctor of chiropractic is extended a new member discount of approximately 50% (as opposed to an increased premium), not reflecting any greater risk for a patient seeing a doctor with less experience.31

American rates reflect the inter-professional differences to an even greater degree.  Whereas the U.S. physician could pay $25,000 to $50,000 per year for malpractice coverage, U.S. chiropractors pay annual rates less than $5,000.32,33 The chiropractic profession has a well-established record of safety and efficacy, and the chiropractor’s malpractice insurance rates remain among the lowest across health professions.34 The varying rates are directly related to the risk involved in the doctors’ procedures, the claims filed against them, and the likelihood of future lawsuits.35

Although they are sensationalized in the media when they do occur, claims against chiropractors are very rare.  Your chiropractor’s office consistently proves itself to be one of the safest health care facilities you can choose for your family.

Moving Forward

Unquestionably, there have been decades of misinterpretations, and unfortunately chiropractic myths have been passed down through generations.  Certainly, professional bias has also played a role in the public’s misunderstanding of the safety and efficacy of chiropractic care.  (The U.S. Court of Appeals determined in 1990 that the American Medical Association had engaged in a “lengthy, systematic, successful and unlawful boycott” designed to restrict cooperation between medical doctors and doctors of chiropractic.36)  Fortunately, we are long past that day.  What you would hope to find in the 21st century are cooperative teams of health care professionals working together for your benefit.

My personal recommendation is to seek a chiropractor who not only uses current technology and techniques to analyze and render care to his or her patients, but also is willing to engage in dialogue with your other health care providers.  I recommend the same when choosing an M.D.

With this better understanding of chiropractic myths and the benefits of maintaining a healthy spine, I trust that you can comfortably move forward, integrating chiropractic care into your wellness lifestyle.